Provider Demographics
NPI:1992183461
Name:CRYSTAL SEASONS ALF LLC
Entity Type:Organization
Organization Name:CRYSTAL SEASONS ALF LLC
Other - Org Name:CRYSTAL SEASONS ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-410-5209
Mailing Address - Street 1:4044 GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1942
Mailing Address - Country:US
Mailing Address - Phone:516-410-5209
Mailing Address - Fax:
Practice Address - Street 1:222 S MURPHY ST
Practice Address - Street 2:
Practice Address - City:LAKE CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:56055-2128
Practice Address - Country:US
Practice Address - Phone:516-410-5209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility